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48 Geriatric analgesia
The common error with this approach, however, is to conclude that the low
dose is the safe dose, and the adequate dose, and that more than the low dose
is contraindicated. This is one of the legends that leads to hypoanalgesia. The
patient must be carefully and frequently monitored so that more analgesia can
be given soon enough to relieve pain, while the patient is being carefully
observed for the development of undesirable side effects.
There are some opioids that should be avoided in geriatric patients.
Specifically, clinicians should try to avoid propoxyphene, codeine, and
meperidine (pethidine). 30–33 The analgesic benefit of these agents fails to
counter the associated risks, which include impaired mental performance,
delirium, falls (and hip fractures), ED visits and hospitalizations, and death.
Side effects of opioids are a reasonable source of concern. The most important
are respiratory depression and constipation. In general, however, the risk
of these negative effects with opioids is outweighed by the benefits of analgesia.
The clinical impact of opioid-related respiratory depression can be minimized
by drug titration and observation for development of side effects. For
patients in the ED, serious respiratory depression from parenteral opioids is
best “treated” by prevention, but hypoventilation can be addressed with
ventilatory support. When necessary, naloxone can be given, but administration
of an opioid reversal agent usually translates into difficulty with
subsequent pain management.
One of the most common adverse effects with opioids is constipation.
Fortunately, constipation is relatively easily prevented with combination
short-term therapy with both a stool softener (e.g. docusate) and a gentle
laxative (e.g. senna). Stimulant laxatives (e.g. bisacodyl, cascara sagrada),
while listed as “inappropriate” by Beers criteria, are occasionally indicated
for short-term use with opioid analgesia. 32
n Summary and recommendations
First line:
n acetaminophen for mild pain (650 mg PO QID)
n hydrocodone for moderate pain (2.5–5 mgPOq4–6h)
n morphine for severe pain (initial dose 0.05 mg/kg IV, then titrate)